The present embodiments relate to quality improvement in patient care. In particular, areas for improving patient care at a medical institutions are identified.
During treatment of patients, hospitals collect considerable amounts of information related to patient care. The collected data includes basic information, such as the date and time of visit/admission, patient age, attending doctor, responsible nurse(s), admitting hospital unit, department that provided the service(s), billing code, and many other variables. The data may also include more detailed information, such as patient symptoms, medications administered, and procedures performed. The data is stored as structured or unstructured data in a computerized patient medical record. This computerized medical record includes the variables and/or values for the variables. Hospitals generally maintain records of these variables and values for a large collection of patients.
Healthcare institutions measure their quality of care using predefined criteria. Often, the criteria are based on whether specific events or processes were followed during patient care. In many instances, the identification of such events requires chart abstraction or analysis. The chart information is examined to determine whether the events or processes occurred during treatment of a given patient. Chart abstraction is a time consuming manual process.
Automated chart abstraction may be provided. For example, the Soarian® Quality Measures program manages and facilitates automatic chart abstraction. The computerized patient record (e.g., structured defined data fields and/or unstructured text or images) is mined to determine whether the events occurred and/or were documented. A score is determined based on the number of patients for which the required events occurred and did not occur (likewise were documented or no). The computerized patient record is also mined to gather and process information. Example of information that is gathered includes discharge medications (e.g.; drug name and dosage), patient admission/arrival date and time, patient surgery date and time, attending physician, admission diagnosis, admitting hospital unit, patient condition, medical procedures applied, etc.
The quality of care indicates overall performance by the hospital for a condition. Where a hospital desires to improve the quality of care, the quality of care measurements may indicate in what measures/care elements the hospital is failing more or failing less, but provides little guidance on how to improve the quality of care.